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a r t i c l e
i n f o
Article history:
Received 31 July 2014
Received in revised form 22 August 2014
Accepted 23 August 2014
a b s t r a c t
Introduction: Early respiratory support and airway (AW) control with endotracheal intubation (ETI) are crucial in
mass toxicology events and must be performed while wearing chemical personal protective equipment (C-PPE).
Aim: The aim of this study is to evaluate the efciency of AW control by using second-generation supraglottic AW
devices (SADs) as compared with ETI and rst-generation SAD while wearing C-PPE.
Methods: This is a randomized crossover trial involving 117 medical practitioners. Four AW management devices
were examined: endotracheal tube, the rst-generation SAD, laryngeal mask AW unique and 2 secondgeneration SAD, the laryngeal tube suction disposable, and supreme laryngeal mask AW (SLMA). Primary end
point measured were success or failure, number of attempts, and time needed to achieve successful device insertion. Secondary end point was a subjective appraisal of the AW devices by study population.
Results: More attempts were required to achieve AW control with endotracheal tube, with and without C-PPE
(P b .001). Time to achieve AW control with ETI was, on average, 88% longer than required with other devices
and improved with practice. The mean times to achieve an AW were longer when operators were equipped
with C-PPE as compared with standard clothing. Subjectively, difculty levels were signicantly higher for ETI
than for all other devices (P b .0001).
Conclusions: When compared with ETI, the use of SADs signicantly shortened the time for AW control while
wearing C-PPE. Second-generation SAD were superior to laryngeal mask AW unique. These nding suggest
that SADs may be used in a mass toxicology event as a bridge, until denite AW control is achieved.
2014 Elsevier Inc. All rights reserved.
1. Introduction
Recent events in the Middle East have refocused attention on the potential threat of using chemical warfare agents in cases of military conict as well as against civilian population [1].
The leading cause of mortality in many cases of mass intoxication is
acute respiratory failure. Most chemical warfare agents as well as other
toxic industrial compounds result in respiratory distress and failure by
assortment of mechanism, including bronchospasm, bronchial secretions, and alveolar loss. Other mechanism involve depression of the
ventilatory drive and respiratory muscles paralysis such as in case of
organophosphates (OPs) nerve intoxication [2-4]. The latter are particularly lethal because of their extremely high toxicity [5].
Chemical personal protective equipment (C-PPE) is crucial to prevent
secondary contamination of the caregivers, before the victims undergo
1446
Fig. 1. Size, 7.0 mm ETT (A), LMAU (B), LTS-D (C), and SLMA (D).
clothing. Each AW control procedure included up to 3 device insertion attempts. Procedure failure was dened as 3 sequential unsuccessful attempts. Correct device insertion was determined by visualization of lung
expansion of the AW managment trainer using bag valve ventilation.
Each participant inserted a lubricated gastric tube size 16 through
the gastric channel of the SLMA and LTS-D and through the nostril of
the simulator with the ETT. A gastric tube was not used in conjunction
with the LMAU, as this is not possible with this device.
In addition, all participants were asked to evaluate their perceived difculty of insertion for each device (1, extremely challenging; 10, very easy).
Primary end point measures included success or failure to achieve
AW control, number of attempts to achieve AW, and time to achieve
successful intubation. A secondary end point was subjective assessments of each AW device and gastric tube insertion.
2.1. Statistical analysis
Dichotomous measures for AW control were compared across device categories using 2 tests. Comparisons of mean number of attempts to successful AW control, mean time to AW control, and selfreported difculty levels were performed using Student t test and
were calculated for both the overall study population and for
category-specic strata. Operator performance measures for each SAD
were compared primarily to the respective value for ETI and secondarily, for mean time to AW control, to each other. A subset analysis of
mean time to successful AW was conducted, limiting the observations
Table 1
Participant age, experience, and self-reported skill level, by medical specialty
Overall
By medical specialty
Medics
Paramedics
GPs
Residentsa
Anesthesiologistsa
a
n (%)
b1
1-3
N3
117 (100)
24.7 7.2
80 (68.4)
12 (10.3)
24 (20.5)
6.8 1.8
26 (22.2)
27 (23.1)
24 (20.5)
20 (17.1)
20 (17.1)
19.4 1.1
19.4 1.0
26.7 1.3
35.2 5.2
25 (21.3)
27 (23.1)
21 (17.9)
6 (5.1)
1 (0.9)
1 (0.9)
0 (0.0)
3 (2.6)
8 (6.8)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
5 (4.3)
19 (16.2)
7.4 1.7
7.2 0.9
6.0 1.3
6.1 2.6
Data on experience level are missing for 1 resident. Age and self-reported skill level were not recorded for anesthesiologists.
Table 4
Results (P values) of comparisons of mean times with AW control, by device type
Device type
Overall
Occupation
Medic
Paramedic
GP
Resident
Anesthesiologist
ETT
LMAU
LTS-D
SLMA
1.11
1.23
1.15
1.01
1.13
1.00
1.00
1.01
1.00
1.01
1.00
1.00
1.01
1.01
1.01
1.00
1.00
1.00
1.00
1.05
1.01
1.02
1.03
1.00
Overall
Occupation
Experience
Skill
Medic
Paramedic
GP
Resident
Anesthesiologist
b1 y
1-3 y
N3 y
1-6
7-10
ETT
LMAU
LTS-D
SLMA
31.7
39.6
27.0
32.8
31.9
26.1
33.0
31.5
27.5
34.0
31.9
17.2
21.8
15.5
18.4
16.0
13.1
18.5
16.5
13.7
18.9
17.5
18.1
21.0
16.3
20.3
18.8
13.1
19.4
17.9
14.2
20.4
18.5
17.7
19.6
15.7
19.0
20.1
13.7
18.4
18.7
14.8
19.7
17.9
1447
ETT
LMAU
LTS-D
SLMA
ETT
LMAU
LTS-D
SLMA
0.00
0.00
0.21
0.00
0.51
0.40
ETT
LMAU
LTS-D
SLMA
Without
With
P
28.8
34.7
b.0001
15.6
18.9
.001
16.8
19.5
b.0001
16.8
18.6
.001
P values are for t test comparison with ETT group, P b .0001 for all comparisons.
1448
Table 6
Mean time (seconds) to successful AW control using PPE, by subject characteristic and
device type
Device type (mean time, in s [P])
Overall
Occupation
Experience
Skill
Medic
Paramedic
GP
Resident
Anesthesiologist
b1 y
1-3 y
N3 y
1-6
7-10
ETT
LMAU
LTS-D
SLMA
34.7
42.0
29.6
34.8
36.1
30.4
35.5
34.1
32.5
36.9
34.7
19.0
24.2
16.8
21.3
16.2
14.3
20.7
17.3
14.8
20.6
19.9
19.5
23.9
16.6
21.8
19.3
14.3
21.0
18.2
15.6
21.9
20.1
18.6
20.7
16.2
19.5
20.9
15.1
19.0
20.4
16.3
20.5
18.7
[11,12], SAD [26-28], and ETI aids [29]. However, most of these studies
were done on a small samples [11,12,26], were limited to anesthesiologists or paramedics [11,12,25,28,29], or did not compare ETI with SADs
[12,26-28]. None of these studies compared second-generation SADs
with ETI and rst-generation SADs in these groups of medical caregivers.
When comparing ETI with SAD insertions, SADs (both rst and second
generation) required less attempts to achieve AW control, with and without C-PPE. Moreover, mean times to successful AW control using the
same device were signicantly longer when participants were equipped
with C-PPE for all devices. This was most pronounced for the ETI with
an approximately 20% increase in time for AW control. We believe that
this difference could be explained by loss of ne motor abilities and dexterity due to C-PPE. Prolongation of the time needed to achieve AW control might inuence morbidity and mortality, especially when dealing
with a large number of casualties.
Second-generation SADs have few advantages over rst-generation
SADs. The main advantage of using is in its ability to achieve both ventilation and gastric content suctioning. Another advantage of the
All occupations
GPs
50
50
40
40
30
30
20
20
10
10
0
0
R1
R2
R3
R1
Medics
Residents
50
50
40
40
30
30
20
20
10
10
R2
R3
R2
R3
R2
R3
0
R1
R2
R3
R1
Paramedics
Anesthesiologists
50
50
40
40
30
30
20
20
10
10
0
R1
R2
R3
R1
Fig. 2. Mean time (seconds) to AW control over repeated practice maneuvers (R1-R3) using personal protective equipment, by occupation and device type.
10
*
6
*
*
0
ETT
LMAU
LTS-D
SLMA
1449
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